Aasha

Welcome to life beyond tax. Our guest today has lead a colorful life.. With the few steps he has accomplished a journey, others may take across life time , he has broken smuggling rackets at the the airport. He Has curbed the illicit trade of the narcotics in sensitive border areas and he has even advice the government of India on trade security & tax policy. As a bright young officer in the Indian revenue services he has held the important & responsible position over 15 years in the government of India, Department of revenue, customs & excise. He went on to study public policy, global health & administration in America & has lectured on global health problems in University of Chicago Mr Sandeep Ahuja is a founder and CEO Operation ASHA. The health NGO which works for TB patients in India & Cambodia. He set up operation ASHA with his colleague Dr Shaily Batra. Together there dream is to eradicate tuberculosis in India & the world. lets meet Mr Sandeep Ahuja, tax commissioner , lecturer, Book writer & now, social entrepreneur. Mr Ahuja welcome to Life beyond Tax. You have been a commissioner, you have been a teacher, you have been a lecturer, you have even written a book & now you are on to something totally new like social entrepreneurship, which cap has been most excited.

Sandeep Ahuja

Each one of them. My life reminds me of values. Two hundred things including working in coal mine. Before we actually started painting and we only know him for his painting, he was looking for his vocation, so I have done many things, I have got many hands and here I am in love what I am doing and that's the journey how has been.

Aasha

So you have studied public policy, health, you studied administration, so why TB now?

Sandeep Ahuja

I will take you to one of my days as under secretary in the ministery of finance. I remember very clearly a meeting after lunch where seven or eight of my colleagues were of my side. And we were just discussing the who had done what? Someone commented that I have been very successful. However I remember going to thinking more and saying oh, I don't think that I have been successful, unless you do something that improve the life of poorest of the poor, last man on this earth, you have not really done, so I said I have not been successful, in spite of everything I might I have done I am failure & I wanted to move on from that failure.

Aasha

You have been nurturing these ideas of atriculism and wanted to do something for the last man standing, but why TB, why tuberculosis?

Sandeep Ahuja

This is neither altruism for me nor sacrifice this is what I love to do and that's it the first thing. Now to your question, why tuberculosis? Dr Shaily and I used to do some work together. She would operate on poor patients for free and I was help her raise the funds. When I went to USA I realized that the science of the philontrophic in the USA market is simply huge. In India, for us philontropy is sight hobby not even a main hobby. That is when I spoke to Shaily and very kindly even though she is gynaeo surgeon she agreed to partner on a big public health issue in which we could levarge our funding with save funding from US and make a much bigger difference in the society. Then when we looked at that various big public health issues around HIV aids, there was lot of big organization working including five nations, polio nearly done. Malaria, moreover sanitation problem, TB nobody business. Even today the funding for TB from international donors is about 20 times less than funding for HIV. A person dies for tuberculosis every ninety seconds in this country. However, I have met very senior cabinet ministers , I have met MPs from districts which are famous for high incidents for TB, who have interrupted me & told me my data must be wrong, that there is no TB, that there is non-single case, in either of the states or districts. It's a shocking state of neglect, so that was the reason we picked up the TB. The second was in TB the government of India provides unlimited medicines. Now in health care you have free medicines it takes care of sixty percent of your expenses. So without even knowing the government actually had a promise and has been fulfilling that promise of funding our NGO to the extent of sixty percent from day one. So these were the key reasons why we got into the TB.

Aasha

How serious is the tuberculosis which is the country with the maximum number of TB patients?

Sandeep Ahuja

Accroding Government of India's estimates India has twenty two lakh new cases every year. More than twice the number in china, unfortunately we lead the pack when it comes to the number of TB patients, not only that we are also leaders when it comes to number of patients of drug resistant tuberculosis. As a matter of that fact we are the only country which has the detected so called totally drug resistant tuercolosis. We are bad. It's a ticking time for us.

Aasha

Why hasn't the government program on TB been effective?

Sandeep Ahujha

The fact is it caters to something like fifteen lakh TB patients every year of all disease programmes in the country. It is the best disease programmes in the country. Allow me to compare our program with Bangladesh a country which has far lower on GDP, on per capita income, it is far poorer, however, there TB incidence rates are much much lower than ours. The reason is that the goverments, the beurocracies, whenever deived , were never design for delivery of services they were designed to rule, they were design to follow, and laydown laws, rules, practices, presidents, they were not supposed to be in business of doing business. Its not meant to do business. Its not suppose to have the flexibility, that you need to deliver health services or any other service.

Aasha

So you would say that for a government program to work then again needs to government needs to collaborate it with a private party.

Sandeep Ahuja

Absolutely. See, how is it work with Bangladesh? Again allow me to go back, the entire top yards, all the doctors, the entire ministerial staffs, where government starts. However you work into a lab half the technicians belong to NGOs and half to the government to go into the field there is no government staff, who deals with the patients. The NGO, the NGO staffs. My people are paid Rs 225 per new enrollment. You perform or you perish.

Aasha

So there is the incentive.

Sandeep Ahuja

To do every key activity there is an incentive to enroll new patients not just find them. If you find the patient and you don't treat whats the point of finding?

Aasha

True!

Aasha

sS identify & bring into the program.

Sandeep Ahuja

Bring into the program. Number one, then TB requires a lot of doses which should be supervised by the health worker. For achieving ninety percent of that number, again, we give five hundred rupees every month. Then we have a minimum treatment success rate of eighty two percent, if someone doesn't achieve that for three months programming, he/she is terminated. Can the government terminate? Governments are not meant, they are not designed through this. So the government should keep it drafts, they should retain the quality political leadership, they should retain the funding. They should retain the middle management and the doctors and the labs .

Aasha

When you set up operation ASHA it became a first organization to use simple and cost effective technology specially the biometric hand health devices. How did you come across this idea?

Sandeep Ahuja

Well I think it is simple. When you do something you have to keep your ego out, you are not the best in charge of how things should be done. You have only done what are patients ask us to do Imagine! That a patient has to come sixty times over six months, meet my health worker or, my health worker has to go to him. Feed him the medicines in his presence, come back, if they are unable to meet for certain reasons then the health worker has to follow up with him on the phone, or with the personal meeting provide him further counseling and bring him back to the system, if that is not done the patient defaults, statistically half the patients who default will become drug resistant.

Aasha

that's right!

Sandeep Ahuja

The length of the treatment will go up by four times. For six months to twenty four months. Worse than that the cost of the treatment will go up from the few thousand to two lakhs atleast, where is that money come from? If this person is not going to get treated the mortality rate is eighty percent he is gonna die. Worse than that each TB patient affects twelve others before dying. So he is going to infect twelve others with that drug resistant strain. He has become a messenger of death. So, the first thing is if you do TB you must reduce the default rate to actually zero. Right! Do human have got that kind of integrity? Obviously not! Will our patient be so truthful ? No. What will be our default rates , what am I doing? Even with the ten percent default rate ,believe me asha I am actually hurting the society. By creating more drug resistant than the normal TB I am treated, I should shut down my TB program. The only way to manage all this well and keep my default rate low and actually no the truth. I had to develop some technology, so finally we were able to tie up with Microsoft research and they develop the technology probono. And that is how we started with the technology.

Aasha

But it is not the government of india introducing biometric devices into their administration of the TB program?

Sandeep Ahuja

No not in the TB program.Yet, they are doing it for attendance, they are doing it for many things.

Aasha

And I also find that operation AASha has set up its centres say in a little area doctors clinic, or in the area of temple, why is that?

Sandeep Ahuja

Many reasons. Who are you and I to treat TB it's the community that serves the community. That is our mantra. So its community serving community. We are partnering with them. That is the key reason why it is the temple, why it is the phone booths, why it is the local medical?

Aasha

And operation asha is working in India & in combodia. What is the difference you find in operations in both of these countries?

Sandeep Ahuja

I will give you a simple example that will explain everything in combodia when we were two years old we wanted to expand to a new pervence. We did our homework, we were allowed to. now one of the things we do in every rural or tribal areas , the labs are far away, so what we do, we tie up with lab technicians and our workers collects samples from the villages and transport them to the lab , on the day when the technician is there. It practically takes that lab to the patient doorstep. That makes detection far more easier. Now in second provence, we were told no this is not allowed. Now the local staff which is mostly Cambodian asked my permission to speak to the national TB manager, which is the head of national TB program in the country. Now I was like, no no hold on this will be treated like complaint. Please try and tell when the district officers and the provential officers finally after twenty days I have relented and I thought I have taken a huge risk by allowing my country director to report to the national leadership. That our workers will not be allowed to transport spurtum. In that provience and most districts, I was so afraid I cant tell you. I thought our TB program in Cambodia might be shut down, so our country director writes an email to the national TB management, believe me what happens, actually its unbelievable. With in seven minutes I am repeating, with in seven minutes we get an email back from him which says, 'I have spoken to the provential director and the district director transporting spurtum is now a part of national guidelines'.

Aasha

Awww!

Sandeep Ahuja

Next paragraph, if you still have problems get back to me. We are partners in it together. Seven minutes, nobody would get an acknowledgement seven minutes in India.

Aasha

And how is this different in india?

Sandeep Ahuja

Aah, India as I said earlier, the things are much more complicated there are many levels of governance, so inspite of our model that has work so well we still serve only half percent of the Indian market.

Aasha

And how many centres do you have in india?

Sandeep ahuja

Right now about two hundred and fifty.

Aasha

ok

Sandeep Ahuja

And hundred twenty five in Cambodia.

Aasha

Wonderful.

Sandeep ahuja

Then there are others Kenya and Uganda , and Dominiac Republic which are not formally our centres because we do not have our own staff there. So all the work there is done by local NGOs. Whom we have trained on our methodology and technology.

Aasha

And what are the challenges you have seen for operation asha in the next ten years?

Sandeep Ahuja

Now if you ask me it has been very good going, so it started tuberculosis however in the very first year of our existence a senior consultant from Mckensy said Sandeep what you have developed is a delivery pipeline. It can be used to deliver any products and services through the bottom of the pyramid balance to the disadvantage. Now we deal with four or five diseases, tuberculosis, haemophelia, heart care, diabetes, so we are not just into TB. So its gonna become a comprehensive pipeline. Now the only thing we are waiting for is how soon we can apply our model to entire healthcare, provide a very high quality care to the villages and slums and connect them for complicated cases. To the secondary intersery centers and cut out there entire chain of unqualified medical practitioners. That is what is going to happen, one. The second thing I am waiting for is the day when in India we will not have a single missed case of TB. Right now there are several unknown, undiagnosed cases every year, who go on impacting others, so that will be my second target. The third will be the day when our technology and strategy will be present in say in twenty countries and then finally across the world.

Aasha

Now from commissioner to social entrepreneur when you look back have you really got what you wanted?

Sandeep Ahuja

More than that. Did I really for avoid of tax system of country? No. Right! Without me the department continues as well, or as bad. Whatever you want to carry.

Aasha

I must thank you for being with us, I wish you all the success in your journey ahead.

Sandeep Ahuja

It's a pleasure and an honour I must say the real success rely if I can make some people in the tax department and may be in the health department in the government of India and possibly governments across the world develop better policies and programs and implement them better for our TB patients and if together we can save many more lives then we do today. Thank you.

Aasha

Sure. Thank you Mr Ahuja!